31 st Annual Conference Indian Association of Preventive and Social Medicine Health Sector Reforms:Relevance for India 27 th February 2004 Dr. Dinesh Agarwal,

31st Annual Conference Indian Association of Preventive and Social Medicine

Health Sector Reforms:Relevance for India27th February 2004

Dr. Dinesh Agarwal, M.D.,Technical advisor (Reproductive Health)

UNITED NATIONS POPULATION FUND, INDIA

Scope of Presentation

Health Sector in India and Characteristics Health System Outcomes: Ultimate and

Intermediate What are reforms? Do we need reforms in Health Sector? Building A Reforms Agenda for India Conclusions

Health System in India : Composition

Treatment providers Different pathies, Formal and informalWide settings

Preventive and Promotive Care

Immunization, Family Planning

Financing mechanisms

Governments, Out of pocket,Insurance

Contd……

Health System in India : Constituents

Input ProducersMedical,Nurs.collegesPharma, diagnosticInstruments

Planner and Health Managers

PEOPLE , INSTITUTIONS ANDACTORS WHO WORK FOR

HEALTH

Health System in India : Characteristics

Vast and Complex: Multiple Planners and number of providers

21% of Global burden of Diseases (16% population)

25% of all Maternal Deaths

Contd……

Health System in India : Characteristics

Conflicts : Patient Care, Training and Research

Politics Influences: Goals, Priorities and Strategies: Variations in Commitment

Evolution of Health System reflect culture, history and norms

Goals of Health System

1. Health Status of Population

Life Expectancy

DALYs lost

Morbidity and Mortality rates

Contd……

Goal of Health Systems

2. Customer Satisfaction/Systems responsiveness

Client Satisfaction (NFHS)

May depend on non-clinical aspects of care

Difficulty in measurement

Contd……

Goal of Health Systems

3. Financial Risk Protection

Are People protected against high cost of medical care?

Catastrophic Illnesses – Poor People

How are we doing ?

Improved Life Expectancy:Yet averages mask equity perspectives ( Class, regional &gender) (49 years in 1970 to 63 years in 1998)

High mortality and burden of diseases among poor: IMR,Diarrhea Diseases etc

Client Satisfaction: “High” level in large scale data setsHealth Sector most corrupt (Transparency International)

Contd……

How are we doing ?

Overall Government spending 0.9% GDP – Bottom quintile in world( WHO 2001)

Private Expenditures: 80% of all spending on health

Nearly 40% of hospitalized in 1995-96 fell into debt.

Large Scale Inter-State Variations: Risk of falling in debt after hospitalization (17% in Kerala – Double in UP/Bihar)

Ref: Mehal et al 2001

Delivery of Public Health Services: Who uses??

1. Richest quintile consumes 3 times more public health resources as compared to poor

2. Most States reflect “Pro-rich” distribution

3. Health needs of urban poor, marginalized and Tribal population

Intermediate Outcomes of Health Systems

Efficiency

Quality

Access

Financial Burden

These are widely discussed characteristics ofHealth system performanceThese are means to an end

Source: GHRR-HSPH, 2003

Efficiency

Using resources in the best possible manner to achieve goalsTechnical Efficiency: How do we produce Output/s?Allocative Efficiency: What we produce?While TE is essence of management, AE is more linked to political economy of health

Example: Maternal Mortality in India

Quality

Degree to which goods and services performas desiredSeveral Definitions,framework and approachesNo term is health systems more abusedMultiple players-Management,Insurance comp.

providers,Clients and CommunityCausality important-Influences both health status/Satisfaction–widely discussedClinical and Service quality dimensionDifferent budgets give different quality!!

Quality of Health Care in India Public/Private Systems

Hospital Care Quality: ALOsAmbulatory Care: Multiple VisitsPreventive and Promotive

Use of Clinical Care protocols, guidelinesQuality of equipments, supplies and MedicinesService Quality Issues:

PrivacyConfidentialityAmenities

HIGHLY VARIABLE:WORLD CLASS to THIRD CLASS

Access

Availability of ServicesEffective Availability

Socio-culturalEconomicDistance

Utilisation (Marker of Demand)

Ability of Clients to use services they wish to use!

Access : Example

1. Availability of women providers at SCs/Outreach2. Are visits regular/predictable – “Up-down” Phenomena3. Gender of providers, culturally appropriate:Jargon4. Economic access – Opportunity Cost – Flexible payment5. Utilisation – distance factor6. What is the package of services?7. Can poor women negotiate use of health services??

Womens access to Primary Reproductive Health Care

Source: Gender Mainstreaming in RCH II – A Report

National Context for Reforms

1. Demographic Transition

(Shift from high fertility/mortality to low

mortality and fertility)

2. Epidemiological Transition( Disease Patterns)

3. Social Transition – High Expectations

4. Technological Transition – Rapid diagnostics,

Therapeutic modalities

5. Health Systems performance problems widely

Acknowledged

6. Demand for increasing allocation (NHP)

What do we mean by “HSR”?

“Purposeful” efforts to change the system to

improve its performance

Rational/logical

Specify goals

Use evidence based strategies

Limited “r”eforms: Small changes

Big bang “R”eforms: Sweeping changes

Source: GHRR-HSPH, 2003

Reforms Agenda for India

1. Health Policy Process – Decentralization, devolution, delegation:

“ONE SIZE DOES NOT FIT ALL”

2. Content: Comprehensive, EpidemiologicalTransition, Standards,private sector

3. Oversight function – Regulation(Clinical establishment, PNDT, HOT Acts)

4. Health Financing Options

Barriers to “Reforms”

1. Reforms are “Hard” Choices: Truly Difficult2. Often consequences of actions are difficult to

predict3. Doing better for one goal may not necessarily

lead to improvement in other goals4. Resistance to “Change” “Status quoists”5. Those who can benefit from reforms are not

powerfully/less organised

THANKS